ACUTE & CHRONIC ACUTE & CHRONIC ADENO TONSILLITISADENO TONSILLITIS

Dr. P. Karthikeyan D.L.O.,DNB(ENT)Dr. P. Karthikeyan D.L.O.,DNB(ENT) Professor & HOD,Professor & HOD,

Dept. of ENT,Dept. of ENT, MGMC&RI.MGMC&RI.

Waldeyer’s Ring consist ofWaldeyer’s Ring consist of1. Adenoids1. Adenoids2. Tubal tonsils2. Tubal tonsils3. Palatine tonsils3. Palatine tonsils4. Lingual tonsils4. Lingual tonsils5. Pharyngeal bands5. Pharyngeal bands

Naso pharyngeal bursaNaso pharyngeal bursa

It is an epithelial lined median It is an epithelial lined median recess found within the adenoid mass and recess found within the adenoid mass and extends from pharyngeal mucosa to the extends from pharyngeal mucosa to the periosteum of the basiocciput.periosteum of the basiocciput. It represents the attachment of It represents the attachment of notochord to the pharyngeal endoderm notochord to the pharyngeal endoderm during embryonic life.during embryonic life.

Rathke’s pouch• It is represented clinically by a dimple

above the adenoids.• It is reminiscent of the buccal mucosal

invagination, to form the anterior lobe of pituitary

Lymphoid tissue in Lymph Node waldeyer’s ring

1. Subepithelial in Position Subcutaneous

2. No demarcation between It has cortex, Cortex and medulla medulla and germinal

centre.3. Partly capsulated or non Capsulated capsulated4. Crypts or furrows - No crypts present5. No afferent, only efferent Both afferent and efferent.

Adenoids Tonsil1. Luscka’s tonsil Faucial tonsil2. Unilateral Bilateral3. Furrows seen Crypts present

4. Present in the posterosuperior Between pillars-Oropharynx wall of the nasopharynx

5. Pseudostratified ciliated Stratified squamous columnar epithelium epithelium

6. Truncated pyramid Almond shaped

7. Uncapsulated Partly capsulated

8. Regresses completely Persist. after puberty

• A tonsil presents two surfaces – a medial and a lateral, and two poles – an upper and a lower.

MEDIAL SURFACE• Covered by non keratinising stratified

squamous epithelium• 12 – 15 crypts.• One of the crypts, situated near the upper

part of tonsil is very large and deep and is called crypta magna or intratonsillar cleft

LATERAL SURFACE• Well defined fibrous capsule, between the

capsule and the bed of tonsil is the loose areolar tissue- peritonsillar space.

• Buccopharyngeal fascia.• Superior constrictor & Styloglossus

muscles• Pharyngobasilar fascia.• Facial artery, submandibular salivary

gland, medial pterygoid muscle and the angle of mandible.

• Tonsillar branch of facial Artery. This is the main artery

• Ascending pharyngeal artery from external carotid.

• Ascending palatine, a branch of facial artery

• Dorsal linguae branches of lingual artery• Descending palatine branch of maxillary

artery

• Venous drainage Paratonsillar vein- Dennis brown vein• Lymphatic drainage Jugulodigastric (tonsillar) node – ½ -1

inch below and behind the angle of mandibule

• Nerve supply Lesser palatine branches of

sphenopalatine ganglion (CN V) and glossopharyngeal nerve provide sensory nerve supply.

AdenoiditisAdenoiditis

Signs & symptoms1. Nasal 2. Ear3. General

Adenoid facies

Postnasal examination of Adenoids

General symptoms Adenoid facies

Elongated face with dull expression Open mouth The prominent and crowded upper teeth Hyperplasia of gums Hypoplasia of maxilla Loss of nasolabial fold Pinched nostrils High arched palate Drooling of saliva.

Loss of appetite Abdominal pain – Mesentric adenitis

X-ray shows Protruded teeth and crowded teeth

X-ray lateral view of Nasopharynx showing Adenoids

Investigation1. Blood investigations2. X ray soft tissue Naso pharynx lateral view3. Digital palpation 4. Nasal endoscopy

TreatmentAdenoidectomy

ADENOIDECTOMYIndications Adenoiditis Adenoid hypertrophy causing sleep apnoea syndrome. Chronic secretory otitis media associated with adenoid

hyperplasia. CSOM with adenoid hyperplasia (Focal sepsis)

Contraindications

Cleft palate or submucous palate. Bleeding diathesis. Acute upper respiratory tract infection.

Adenoidectomy

COMPLICATIONS Haemorrhage usually seen in immediate post-operative

period. Injury to Eustachian tube opening. Injury to pharyngeal musculature and vertebrae due to

hyperextension of neck. Gracielle’s sign – Anterior spinal ligament will get injured while

doing overenthusiastic adenoidectomy and produce neck stiffness.

Velopharyngeal insufficiency. Nasopharyngeal stenosis due to scarring.

Tonsil consists of 1. Surface epithelium2. Crypts3. Lymphoid tissue

ACUTE TONSILLITIS

Types1) Acute follicular Tonsillitis2) Acute Parenchymatous Tonsillitis3) Acute membranous Tonsillitis

Etiology1) Group A Beta heamolytic streptococcus.

Staph, Pneumococci, H.influenzae2) Secondary to viral infection

Clinical FeaturesSymptoms1) Throat pain2) Difficulty in swallowing3) Painful swallowing4) Sore throat5) Earache - Referred, Aom6) Abdominal Pain7) Constitutional symptoms

Signs1) Foetid breath and coated tongue2) Congestion3) Sometimes trismus4) Tender JD nodes

TreatmentConservative

ComplicationsChr. TonsillitisAbscessTonsillolithRheumatic feverAGNSubacute bacterial endocarditis

D.D of membrane over the TonsilD.D of membrane over the Tonsil1) Membranous Tonsillitis2) Diptheria3) Vincent’s angina4) Im5) Agranulocytosis6) Leukaemia7) Apthous ulcers8) Oral thrush

Chronic TonsillitisChronic TonsillitisEtiology:1) Complication of Acute Tonsillitis2) Chronic Sinusitis may be a predisposing

factorTypes:

1. Chronic follicular2. Chronic parenchymatous3. Chronic fibrotic

Clinical featuresSymptoms:1) Recurrent attacks of sore throat2) Difficulty in swallowing3) Chronic cough4) Throat irritation

Signs1) Congestion of anterior pillar2) May enlarged or fibrotic3) Squeeze test or Irwin Moore sign4) Non tender JD nodes

InvTC,DC,ESRHb%BT,CT, platelet countUrine - alb, sugarBlood grouping & typhing.Blood urea & sugarASO titreThroat swab

Treatment1) Conservative2) Tonsillectomy

TONSILLECTOMYIndication

Chronic tonsillitis Recurrent attacks of acute tonsillitis 4-6 weeks following an attacks of peritonsillar abscess (Interval

tonsillectomy) Huge tonsil causing obstructive sleep apnoea syndrome. Huge tonsil causing mechanical obstruction to swallowing. Persistent carrier of Group – A Beta Haemolytic streptococcus

or diptheira bacilli. Sarcoma or lymphoma Benign tumours – Fibroma, papilloma.

UNILATERAL

1. Approach Glosso-pharyngeal neurectomy in glossopharyngeal neuralgia

Elongated styloid process. UPPP

2. Tonsillar cyst, Tonsillolith.

3. Foreign body – tonsil.

4. Suspected malignancy for biopsy.

Methods of Tonsillectomy

1. Dissection method2. Laser (Light amplification by stimulated emission of radiation )

Advantage: Less bleeding, less pain, less scarring, quick healing.

Disadvantage: Cost of laser therapy is high..

3. Cryosurgery It utilizes freezing for excision of tissues with the help of

cryoprobe. Nitrous oxide cryoprobe can achieve a temperature of – 70c while liquefied nitrogen can cool upto –196c. Mode of action:1. Cell membrance ruptures due to the formation of intracellular ice crystals.2. Intracellular dehydration occurs due to ice crystallization.3. Proteins become denatured.4. Enzymatic inhibition follows destruction of cellular metabolism.5. Local ischaemia and microthrombosis of blood vessels occur.

Advantage: Less bleeding, less pain Dis advantage: Histopathology of the excised tissue is not

possible due to destruction of the tissue by freezing.

4 . Radiofrequency method 5 . Coblation Method

Advantage: Less bleeding, less pain, less scarring, quick healing.

Disadvantage: Cost is high..

Contra indications

Absolute1. Bleeding diathesis2. Aneurysm of internal carotid artery.3. Acute infection

Relative

1. During epidemic of polio.2. Severe diabetes and hypertension.3. Gross allergy and severe asthma.4. Children under 3 years of age.5. Hemoglobin level less than 10g %

Complications1. Haemorhage Primary Reactionary Secondary 2. Aspiration pneumonia3. Collapse of lung4. Injury to tonsillar pillars, uvula, soft palate results in nasopharyngeal incompetence and nasal intonation.5. Dental injury6. Scoline apnoea – common in vaishnavas due to pseudocholine esterase deficiency. 7. TM joint dislocation8. Tonsillar remnants9. Hypertrophy of lingual tonsil.

THANK

YOU

PERITONSILLAR ABSCESS PERITONSILLAR ABSCESS (QUINSY)(QUINSY)

It is a collection of pus in the peritonsillar It is a collection of pus in the peritonsillar space which lies between the capsule of space which lies between the capsule of tonsil and the superior constrictor muscletonsil and the superior constrictor muscle

AETIOLOGY• Peritonsillar abscess usually follows acute

tonsillitis• First, one of the tonsillar crypts, usually the

crypta magna, gets infected and sealed off. It forms an intratonsillar abscess which then bursts through the tonsillar capsule to set up peritonsillitis and then an abscess.

• Culture of pus• Growth of strept. Pyogenes, staph.

Aureus or anaerobic organisms. More often the growth is mixed, with both aerobic and anaerobic organisms.

CLINICAL FEATURES• Peritonsillar abscess mostly affects adults

and rarely the children though acute tonsillitis is more common in children

• General• Fever (up to 104◦F) chills and rigors,

general malaise body aches headache nausea and constipation

• Local• Severe pain in throat• Odynophagia• Muffled and thich speech often called “hot

potato voice”

• Foul breath due to sepsis in the oral cavity• Ipsilateral earache. This is referred pain via CN

IX which supplies both the tonsil and the ear.• Trismus due to spasm of pterygoid muscles• EXAMINATION• The tonsil, pillars and soft on the involved side

are congested and swollen• Uvula is swollen and oedematous and pushed to

the oposite side• Bulge of the soft palate and anterior pillar• Cervical lymphadenopathy is commonly seen• Jugulodigastric lymph nodes• Torticollis, patient keeps the neck tilted to the

side of abscess.

TREATMENT• Hospitalisation• Intravenous fluids to combat dehydration• Antibiotics• Analgesics like paracetamol• Oral hygiene• Incision and drainage of abscess. A

peritonsillar abscess is opened at the point of maximum bulge above the upper pole of tonsil or just lateral to the point of junction of anterior pillar with a line drawn through the base of uvula or midway between base of uvula and 3rd molar.

• Interval tonsillectomy. Tonsils are removed four to six weeks following an attack of quinsy

• Abscess or hot tonsillectomy. Some people prefer to do “hot” tonsillectomy instead of incision and drainage. Abscess tonsillectomy has the risk of rupture of the abscess during anesthesia, and excessive bleeding at the time of operation.

Complication• Parapharyngeal abscess• Oedema of larynx. Tracheostomy may be

required• Septicaemia other complications like

endocarditis, nephritis, brain abscess may occur.

• Pneumonitis or lung abscess. Due to aspiration of pus, if spontaneous rupture of abscess takes place

• Jugular vein thrombosis• Spontaneous haemorrhage from carotid

artery or jugular vein